The scandal of baby heart deaths at Bristol Royal Infirmary could be repeated elsewhere - and even be happening now - warns the report into events at the hospital.

But Health Secretary Alan Milburn has promised action to ensure no parents have to go through such pain ever again.

This is the end of the age of the doctor is right

Trevor Jones

And parents have welcomed the fact that the report was not a whitewash.

The long-awaited report concludes that between 30 and 35 children who underwent heart surgery at the Bristol Royal Infirmary between 1991 and 1995 died unnecessarily as a result of sub-standard care.

And it says a series of flaws in the way the hospital worked meant around one third of all children who underwent open-heart surgery there received "less than adequate care".

The heart unit was split between two sites, with no dedicated children's intensive care beds, no way of monitoring quality and poor organisation.

Report's recommendations

Periodic revalidation should be compulsory for
all healthcare professionals.

The public, as well as employers, should be involved in the processes of revalidation.

Units providing open heart surgery on very young children must have two surgeons trained in paediatric surgery, who must conduct at least 40 operations a year.

Patients and the public must be able to obtain information as to the
relative performance of trusts and consultant units within trusts.

The clinical negligence system should be abolished and replaced by an
alternative way of compensating patients.

A Council for the Quality of Healthcare should be created along with a Council for the Regulation of Healthcare
Professionals

It condemns a "club culture" among powerful, but flawed doctors at the unit, who adopted a paternalistic attitude to patients and were caught up in professional rivalries.

This led to a "Greek tragedy" of events in which warning signs were not recognised and people who raised concerns were ignored and threatened.

Surgeons were able to cover up high death rates by claiming they were on a "learning curve" - and their powerful positions both on the wards and at
management level meant no one was able to question them.

However, it warns: "It is not possible to say, categorically, that events similar to those which happened in Bristol could not happen again in the UK, indeed, are not happening at the moment."

The multi-million pound inquiry was the biggest probe into the workings of the NHS ever carried out.

It says what happened at Bristol was not about "bad people", nor was it about "people who did not care, nor of people who wilfully harmed patients."

Instead, the report says the healthcare staff were "victims of circumstances which owed as much to the general failings in the NHS at the time than to any individual failings".

It recommends measures to beef up regulation of the medical profession in the UK.

It also calls for an urgent investigation to ensure children's heart services are not currently being carried out at units "where the low volume of patients or other factors make it unsafe to perform such surgery".

National director

Speaking in the House of Commons, Health Secretary Alan Milburn said the Bristol children were "failed by the very system that was supposed to keep them safe from harm."

In line with the report's recommendations, he announced a new independent Office for Information on Healthcare Performance to coordinate the collection and publication of medical data, and the appointment of a national director for children's services.

James Wisheart was struck off

Mr Milburn said: "Medicine is not a perfect science even the best people can make the worst mistakes.

"Putting right what can sometimes go wrong relies on the NHS being able to acknowledge error, and having systems in place to minimise error.

"The absence of such an approach at Bristol - and in the wider NHS at the time - contributed directly to the tragedy that cost dozens of children their lives."

Trevor Jones, of the Bristol Heart Children's Action Group, said: "This is the end of the age of the doctor is right.

"We have to now question and get correct answers on doctors' ability and performance."

Huge investigation

The inquiry team, lead by Professor Ian Kennedy, has spent three years investigating why botched operations at the hospital were allowed to continue for 11 years between 1984 and 1995.

Professor Kennedy said: "Children have been let down by the NHS for too long. We can do better and we must do better."

Many parents are grieving children who died at Bristol

Following a General Medical Council investigation, which concluded in 1998, heart surgeon James Wisheart was struck off the medical register.

The surgeon issued a statement following the publication of the inquiry, in which he accepted the findings, and apologised to relatives of children who died.

Mr Wisheart's colleague Janardan Dhasmana was banned from operating on children for a total of four years.

Both were found guilty of serious professional misconduct after they continued to operate on children despite poor survival rates.

The hospital's chief executive John Roylance was also struck off for covering up the surgeon's inadequacies.

The GMC looked at 53 cases involving two types of heart surgery carried out between 1988 and 1995. It concluded that 29 children died after being operated on by Wisheart and Dhasmana.

However, some families of children treated at the hospital have remained fiercely loyal to the disgraced surgeons in the case, claiming they have been used as
scapegoats for underfunding and a wider malaise within the system.

Bristol has already led to major changes in the way medicine in the UK is regulated, including the creation of a new inspection authority, and the introduction of a system of appraisal for doctors.